Association between historical neighborhood redlining and cardiovascular outcomes among US veterans with atherosclerotic cardiovascular diseases

Importance: In the 1930s, the government-sponsored Home Owners\u27 Loan Corporation (HOLC) established maps of US neighborhoods that identified mortgage risk (grade A [green] characterizing lowest-risk neighborhoods in the US through mechanisms that transcend traditional risk factors to grade D [red] characterizing highest risk). This practice led to disinvestments and segregation in neighborhoods considered redlined. Very few studies have targeted whether there is an association between redlining and cardiovascular disease.Objective: To evaluate whether redlining is associated with adverse cardiovascular outcomes in US veterans.Design, setting, and participants: In this longitudinal cohort study, US veterans were followed up (January 1, 2016, to December 31, 2019) for a median of 4 years. Data, including self-reported race and ethnicity, were obtained from Veterans Affairs medical centers across the US on individuals receiving care for established atherosclerotic disease (coronary artery disease, peripheral vascular disease, or stroke). Data analysis was performed in June 2022.Exposure: Home Owners\u27 Loan Corporation grade of the census tracts of residence.Main outcomes and measures: The first occurrence of major adverse cardiovascular events (MACE), comprising myocardial infarction, stroke, major adverse extremity events, and all-cause mortality. The adjusted association between HOLC grade and adverse outcomes was measured using Cox proportional hazards regression. Competing risks were used to model individual nonfatal components of MACE.Results: Of 79 997 patients (mean [SD] age, 74.46 [10.16] years, female, 2.9%; White, 55.7%; Black, 37.3%; and Hispanic, 5.4%), a total of 7% of the individuals resided in HOLC grade A neighborhoods, 20% in B neighborhoods, 42% in C neighborhoods, and 31% in D neighborhoods. Compared with grade A neighborhoods, patients residing in HOLC grade D (redlined) neighborhoods were more likely to be Black or Hispanic with a higher prevalence of diabetes, heart failure, and chronic kidney disease. There were no associations between HOLC and MACE in unadjusted models. After adjustment for demographic factors, compared with grade A neighborhoods, those residing in redlined neighborhoods had an increased risk of MACE (hazard ratio [HR], 1.139; 95% CI, 1.083-1.198; P \u3c .001) and all-cause mortality (HR, 1.129; 95% CI, 1.072-1.190; P \u3c .001). Similarly, veterans residing in redlined neighborhoods had a higher risk of myocardial infarction (HR, 1.148; 95% CI, 1.011-1.303; P \u3c .001) but not stroke (HR, 0.889; 95% CI, 0.584-1.353; P = .58). Hazard ratios were smaller, but remained significant, after adjustment for risk factors and social vulnerability.Conclusions and relevance: In this cohort study of US veterans, the findings suggest that those with atherosclerotic cardiovascular disease who reside in historically redlined neighborhoods continue to have a higher prevalence of traditional cardiovascular risk factors and higher cardiovascular risk. Even close to a century after this practice was discontinued, redlining appears to still be adversely associated with adverse cardiovascular events

Outcomes with Orbital and Rotational Atherectomy for Inpatient Percutaneous Coronary Intervention

INTRODUCTION: Our objective was to describe the contemporary outcomes of orbital atherectomy (OA) vs. rotational atherectomy (RA) use for inpatient percutaneous coronary intervention (PCI) in the United States. Data on the use of OA vs. RA in contemporary inpatient PCI are limited. METHODS: We queried the Nationwide Readmission Database (NRD) from January to November for the years 2016-2017 to identify hospitalizations of patients who underwent PCI with atherectomy. We conducted a multivariate regression analysis to identify variables associated with in-hospital mortality. RESULTS: We included 77,040 records of patients who underwent inpatient PCI with atherectomy. Of those, 71,610 (93%) had RA, and 5430 (7%) had OA. There was no significant change in the trend of using OA or RA over 2016 and 2017. OA was less utilized in patients presenting with ST-segment elevation myocardial infarction (STEMI) (4.3% vs. 46.8%, p \u3c 0.001). In our cohort, OA was associated with lower in-hospital mortality (3.1% vs. 5%, p \u3c 0.001) and 30-day urgent readmission (\u3c 0.01% vs. 0.2%, p = 0.009), but a higher risk of coronary perforation (1.7% vs. 0.6%, p \u3c 0.001) and cardiac tamponade (1% vs. 0.3%, p \u3c 0.001) and a higher cost of index hospitalization ($28,199 vs.$23,188, p \u3c 0.001) compared with RA. CONCLUSION: RA remains the predominant atherectomy modality for inpatient PCI in the United States (93%). There was no change in the trend of use for either modality over the years 2016 and 2017. OA was noted to have a lower incidence of in-hospital death, but a higher risk of coronary perforation and a higher cost of index hospitalization for the overall unmatched cohorts

Historical Redlining, Socioeconomic Distress, and Risk of Heart Failure Among Medicare Beneficiaries.

BACKGROUND: The association of historical redlining policies, a marker of structural racism, with contemporary heart failure (HF) risk among White and Black individuals is not well established. METHODS: We aimed to evaluate the association of redlining with the risk of HF among White and Black Medicare beneficiaries. Zip code-level redlining was determined by the proportion of historically redlined areas using the Mapping Inequality Project within each zip code. The association between higher zip code redlining proportion (quartile 4 versus quartiles 1-3) and HF risk were assessed separately among White and Black Medicare beneficiaries using generalized linear mixed models adjusted for potential confounders, including measures of the zip code-level Social Deprivation Index. RESULTS: A total of 2 388 955 Medicare beneficiaries (Black n=801 452; White n=1 587 503; mean age, 71 years; men, 44.6%) were included. Among Black beneficiaries, living in zip codes with higher redlining proportion (quartile 4 versus quartiles 1-3) was associated with increased risk of HF after adjusting for age, sex, and comorbidities (risk ratio, 1.08 [95% CI, 1.04-1.12]; P<0.001). This association remained significant after further adjustment for area-level Social Deprivation Index (risk ratio, 1.04 [95% CI, 1.002-1.08]; P=0.04). A significant interaction was observed between redlining proportion and Social Deprivation Index (Pinteraction<0.01) such that higher redlining proportion was significantly associated with HF risk only among socioeconomically distressed regions (above the median Social Deprivation Index). Among White beneficiaries, redlining was associated with a lower risk of HF after adjustment for age, sex, and comorbidities (risk ratio, 0.94 [95% CI, 0.89-0.99]; P=0.02). CONCLUSIONS: Historical redlining is associated with an increased risk of HF among Black patients. Contemporary zip code-level social determinants of health modify the relationship between redlining and HF risk, with the strongest relationship between redlining and HF observed in the most socioeconomically disadvantaged communities

Sex‐Specific Associations of Oral Anticoagulant Use and Cardiovascular Outcomes in Patients With Atrial Fibrillation

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/1/jah32481-sup-0001-TableS1.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/2/jah32481.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139084/3/jah32481_am.pd

Current perspectives on coronavirus disease 2019 and cardiovascular disease: a white paper by the JAHA editors

Coronavirus Disease 2019 (COVID‐19) has infected more than 3.0 million people worldwide and killed more than 200,000 as of April 27, 2020. In this White Paper, we address the cardiovascular co‐morbidities of COVID‐19 infection; the diagnosis and treatment of standard cardiovascular conditions during the pandemic; and the diagnosis and treatment of the cardiovascular consequences of COVID‐19 infection. In addition, we will also address various issues related to the safety of healthcare workers and the ethical issues related to patient care in this pandemic